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Carpal Instability Nondissociative Review Article Carpal Instability Nondissociative Abstract Scott W. Wolfe, MD Carpal instability nondissociative (CIND) represents a spectrum of Marc Garcia-Elias, MD conditions characterized by kinematic dysfunction of the proximal carpal row, often associated with a clinical “clunk.” CIND is Alison Kitay, MD manifested at the midcarpal and/or radiocarpal joints, and it is distinguished from carpal instability dissociative (CID) by the lack of disruption between bones within the same carpal row. There are four major subcategories of CIND: palmar, dorsal, combined, and From the Hand and Upper Extremity adaptive. In palmar CIND, instability occurs across the entire Service, Hospital for Special proximal carpal row. When nonsurgical management fails, surgical Surgery, New York, NY (Dr. Wolfe and Dr. Kitay) and the Hand and options include arthroscopic thermal capsulorrhaphy, soft-tissue Upper Extremity Surgery, Institut reconstruction, or limited radiocarpal or intercarpal fusions. In Kaplan, Barcelona, Spain dorsal CIND, the capitate subluxates dorsally from its reduced (Dr. Garcia-Elias). resting position. Dorsal CIND usually responds to nonsurgical Dr. Wolfe or an immediate family management; refractory cases respond to palmar ligament reefing member has received royalties from Extremity Medical and Elsevier; is a and/or dorsal intercarpal capsulodesis. Combined CIND member of a speakers’ bureau or demonstrates signs of both palmar and dorsal CIND and can be has made paid presentations on behalf of TriMed and Small Bone treated with soft-tissue or bony procedures. In adaptive CIND, the Innovations; serves as a paid volar carpal ligaments are slackened and are less capable of consultant to or is an employee of inducing the physiologic shift of the proximal carpal row from Extremity Medical, OsteoMed, and Small Bone Orthopedics; and serves flexion into extension as the wrist ulnarly deviates. Treatment of as a board member, owner, officer, choice is a corrective osteotomy to restore the normal volar tilt of or committee member of the New the distal radius. York Society for Surgery of the Hand. Dr. Garcia-Elias or an immediate family member has received royalties from Tornier; is a member of a speakers’ bureau or he terms carpal instability disso- Conceptually, radiocarpal ligament has made paid presentations on Tciative (CID) and carpal insta- insufficiencies are CIND problems, behalf of OsteoMed; serves as an bility nondissociative (CIND) were in which the entire carpus is translo- unpaid consultant to SBI; and first proposed by Dobyns et al1 in cated in a palmar, dorsal, radial, or serves as a board member, owner, officer, or committee member of the 1985 to distinguish between two ma- ulnar direction, often without a International Federation of Societies jor classes of carpal instability. CID proximal row dissociation. However, for Surgery of the Hand. Neither is characterized by instability be- because their clinical features are so Dr. Kitay nor any immediate family tween bones within a single carpal dissimilar from those observed in pa- member has received anything of 2,3 value from or has stock or stock row. CIND is characterized by dys- tients with a proximal carpal row options held in a commercial function of the entire proximal car- dysfunction, they are not discussed company or institution related pal row, manifested at either the ra- here. directly or indirectly to the subject of diocarpal joint, the midcarpal joint, this article. The typical features of CIND were or both. first identified in 1934 by Mouchet J Am Acad Orthop Surg 2012;20: 575-585 These disorders are frequently as- and Belot, who referred to symptom- sociated with a clinical “clunk.” atic laxity of the carpus as “snapping http://dx.doi.org/10.5435/ 4 JAAOS-20-09-575 CIND may be distinguished radio- wrist.” Since then, several investiga- graphically from CID by the lack of tors have identified subcategories of Copyright 2012 by the American Academy of Orthopaedic Surgeons. a separation or bony break within CIND with subtle differences in pre- the proximal carpal row (Figure 1). sentation and demographics. The no- September 2012, Vol 20, No 9 575 Carpal Instability Nondissociative Figure 1 joint, tenderness to palpation over radial deviation and forearm prona- the ulnar carpus at the triquetroham- tion. The examiner passively trans- ate joint, and painful clunking that lates the distal carpal row and occurred with pronation and ulnar central metacarpals in a palmar di- deviation.4 Lichtman et al6 initially rection, and the wrist is then ulnar- referred to this disorder as ulnar deviated by the examiner. As the midcarpal instability until 1993, wrist is brought into ulnar deviation, when these authors renamed it pal- a dramatic clunk is noted as the mar midcarpal instability to distin- proximal carpal row pops into ex- guish it from reports of dorsal mid- tension (Video 2). The driving force carpal subluxation. Because the of this clunk is the articular surface instability occurs across the entire of the distal carpal row. The helicoi- proximal carpal row and is not iso- dal surface of the hamate forces the lated to dysfunction of either the ra- hyperflexed triquetrum into sudden diocarpal or midcarpal joints, pal- extension, pulling the attached lu- mar CIND (or CIND-VISI) is the nate and scaphoid into extension more descriptive and inclusive term. with it.9 The clunk may or may not be painful. Illustration of carpal instability nondissociative, which represents Clinical Presentation instability at the radiocarpal joint, Patients with symptomatic palmar Pathomechanics the midcarpal joint, or both joints (outlined in red). Unlike patterns of CIND typically report a painful When a normal wrist deviates from a instability in carpal instability clunk while performing activities radial-deviated to ulnar-deviated dissociative, there is no break that require ulnar deviation, such as posture, the three bones of the proxi- between bones within either the pouring liquids. Generalized liga- mal carpal row rotate from flexion proximal or distal carpal rows. mentous laxity is a common finding into extension. Two entities ensure in this population, and many pa- that this rotation is smooth and pro- tients do not recall a specific injury gressive: the palmar midcarpal liga- menclature used to describe these associated with the onset of symp- ments and the coordinated function subcategories has been variable and toms. A volar sag of the ulnar carpus of the flexor carpi ulnaris and ex- confusing at times, but the clinical is often noted on visual inspection tensor carpi ulnaris muscles. Par- entities encompassing CIND can be (Figure 3). The condition is often bilat- ticularly important are the most understood by dividing them into eral, despite presentation with symp- proximal fibers of the triquetral- four major groups: palmar CIND (or toms predominantly in one wrist. hamate-capitate ligament and the CIND-VISI [volar intercalated seg- Persons with congenital ligamentous anterolateral scaphotrapezium liga- mental instability]), dorsal CIND laxity (most frequently women, chil- ments (Figure 5). As the wrist devi- (or CIND-DISI [dorsal intercalated dren, and adolescents) or with patho- ates ulnarly, these two ligaments be- segmental instability]), combined logic ligament laxity (eg, Ehlers-Danlos come progressively taut and pull the CIND, and adaptive CIND (Figure syndrome, cutis laxa) commonly have proximal row smoothly into exten- 2). asymptomatic or minimally symptom- sion. The coordinated contraction of atic palmar CIND. the flexor carpi ulnaris and extensor Palmar CIND Most patients with palmar CIND carpi ulnaris muscles also helps ex- demonstrate the classic catch-up tend the proximal row by realigning The most common type of CIND is clunk (Figure 4) as the proximal car- the flexed triquetrum into a more ex- the palmar type, or CIND-VISI. This pal row pops from a flexed posture tended posture. The results of several disorder was first characterized as a into an extended posture during ra- cadaver-sectioning studies suggest true clinical syndrome by Lichtman dial to ulnar deviation (Video 1). that injury or attenuation of the ul- et al5 in 1981 in a small series of pa- Lichtman and colleagues5-8 de- nar arm of the palmar arcuate (ie, tients who presented with painful scribed a clinical test, the midcarpal triquetral-hamate-capitate) ligament clunking of the wrist. These patients shift test, to demonstrate this clunk. or the dorsal radiotriquetral liga- had a visible or palpable volar de- The patient’s wrist is positioned in ment is also implicated in symptom- pression or sag at the midcarpal neutral flexion-extension, with slight atic palmar CIND5,6,10,11 (Figure 5). 576 Journal of the American Academy of Orthopaedic Surgeons Scott W. Wolfe, MD, et al Figure 2 Diagram of the four subcategories of carpal instability nondissociative (CIND) and the nomenclature by which they are often referred. Nonsurgical management is less successful for combined CIND than for palmar or dorsal CIND. Surgical results for adaptive CIND generally are superior to surgical results for the other subcategories of CIND. CIND-DISI = CIND dorsal intercalated segmental instability, CIND-VISI = CIND volar intercalated segmental instability, CLIP = capitolunate instability pattern, ulnar MCI = ulnar midcarpal instability. (Adapted with permission from Garcia- Elias M: The non-dissociative clunking wrist: A personal view. J Hand Surg Eur 2008;33[6]:698-711, except for the radiographs, which
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